Acute Care Interventions Research Articles

A community hospital cancer services approach to the reduction of OP-35 rule hospitalizations.

e23036 Background: Acute inpatient hospital care contributes substantially to variation in cancer care costs across the United States. The CMS Hospital Outpatient Quality Reporting Program’s OP-35 rule penalizes health systems for having higher-than-expected rates of emergency department (ED) visits or inpatient admissions for ten potentially preventable conditions within 30 days of receiving chemotherapy. To commence a systematic, automated, risk-adapted program to maximize safety outcomes, we identified independent risk factors specific to cancer patients in the Inova Health System (a 5-hospital, 5 million-patients hospital system in Virginia/greater metropolitan DC). Methods: We identified all cancer patients who received chemotherapy within the previous 30 days and presented to the ED or were admitted between 1/1/2018 to 12/31/2021 for one of the OP-35 toxicities as their primary or secondary diagnoses at the time of the acute care evaluation. Data included demographics, insurance coverage, cancer diagnosis, co-morbidities, and status (alive/dead) at last follow up. A zero-truncated Poisson regression analysis was performed in R v4.1.1. We further performed risk analysis within comorbid conditions by creating a matched cohort of patients by sex, age at first treatment, race, and cancer type who did not have an ED or admission visit due to OP-35 events during this same period. Propensity score matching was performed using R package MatchIt v4.5.1. Results: Among the 1,618 patients identified, the most frequent events were pain, sepsis, and fever. 56% of patients were female with an overall median age of 64 (range = [20, 95]). Men were predicted to have 16% more visits than females. 45% had commercial insurance, 39% were on Medicare, and 15% were on Medicaid or charity care. 39% had two or more visits during the 4 years of the study, and among those patients, the most frequent cancer types were gastrointestinal (32%) and breast (22%). Self-reported latino patients constituted 4% of all patients but had the highest average number of events (median = 2.07, range = [1, 9]). Patients who reported more-than-one-race or Asian ancestry had the lowest median number of events (1.56 and 1.64, respectively). In the matched cohort analysis, five co-morbidities were statistically significant (p < 0.05): a previous history of coagulopathy/pulmonary emboli, myocardial infarction, cardiac arrhythmias, depression, and weight loss (concordance = 0.58). 46% of all patients with an event had at least one of these 5 comorbidities. Conclusions: Demographic factors and specific comorbid conditions were associated with risk for requiring acute care intervention for chemotherapy toxicities. Future interventions will include introduction of risk-reducing monitoring in the outpatient setting for higher risk patients identified in this investigation to reduce the need for ED visits and inpatient hospitalizations.

Psychological treatment of neurotraumatic injuries – crisis intervention in acute care

Patients who have suffered a neurotraumatic injury undergo severe physical and psychological trauma, which in many cases also traumatizes their relatives. Severe physical trauma and its long-term consequences have a significant impact on the lives of the people affected and their relatives. Acute health care, as well as the various periods of prolonged hospitalization, are a major physical and psychological challenge for both patients and their relatives. Patients who have suffered severe physical trauma are cared for by a multidisciplinary trauma team, which includes psychological support, too, in line with international professional guidelines. The involvement of psychologists and psychiatrists should be an integral part of acute care in the case of acute stress disorder and early-onset depression. The acute onset of psychological symptoms and the potential for long-term psychological disturbances warrant crisis intervention as close as possible in time and space to the critical event following the traumatic event. In the case of severe somatic trauma, combined therapy (pharmacotherapy and psychotherapy) can be used to relieve these symptoms and timely crisis intervention can reduce psychological symptoms and prevent the development of more serious psychopathologies (post-traumatic stress syndrome, depressive symptoms, anxiety disorders, sleep disorders), which in the long term can significantly impair quality of life and the risk of suicide. Providing regular psychological support helps the patient to adapt to the hospital environment and treatment, improves compliance, supports cooperation with physiotherapists and prepares the patient for rehabilitation. Basic psychotherapeutic care, using a variety of methods related to medical treatments and bodily processes, ranges from crisis intervention through supportive therapy to rehabilitation. It is essential that professional psychological support should be provided for the patient who has suffered a serious physical trauma as well as their relatives.

Factors Associated with Self-Reported Voice Change in the Hospitalized Burn Population: A Burn Model System National Database Study.

Voice plays a prominent role in verbal communication and social interactions. Acute burn care often includes intubation, mechanical ventilation, and tracheostomy, which could potentially impact voice quality. However, the issue of long-term dysphonia remains underexplored. This study investigates long-term self-reported voice changes in individuals with burn injuries, focusing on the impact of acute burn care interventions. Analyzing data from a multicenter longitudinal database (2015-2023), self-reported vocal changes were examined at discharge and 6, 12, 24, and 60 months after injury. Out of 582 participants, 65 reported voice changes at 12 months. Changes were prevalent at discharge (16.4%) and persisted over 60 months (11.6-12.7%). Factors associated with voice changes included flame burn, inhalation injury, tracheostomy, outpatient speech-language pathology, head/neck burn, larger burn size, mechanical ventilation, and more ventilator days (p < 0.001). For those on a ventilator more than 21 days, 48.7% experience voice changes at 12 months and 83.3% had received a tracheostomy. The regression analysis demonstrates that individuals that were placed on a ventilator and received a tracheostomy were more likely to report a voice change at 12 months. This study emphasizes the need to understand the long-term voice effects of intubation and tracheostomy in burn care.

The association between patient engagement and quality of care interactions among acute care patients with dementia

Effective staff-patient communication is critical in acute care settings, particularly for patients with dementia. Limited work has examined the impact of quality of staff-patient care interactions on patient engagement. The purpose of this study was to determine whether the quality of staff-patient care interactions were associated with active patient engagement during the interaction after controlling for relevant covariates. The study was a secondary data analysis using baseline data from the Function Focused Care for Acute Care intervention study, with a total sample of 286 patients. Descriptive statistics and a generalized linear mixed model were used. The findings indicated that there was a significant relationship between the quality of care interactions and patient engagement such that receiving positive care interactions resulted in higher odds of active patient engagement. These findings can inform future interventions and training for acute care staff to improve quality of care interactions and patient engagement.

Frailty in Older Adults with Dengue Fever.

Background and objectives: Dengue is one of the most common epidemic infections around the world. Dengue infections in older adults are related to an atypical presentation and a high mortality. Frailty is associated with poor recovery from hospitalization due to infection. However, few studies describe frailty and functional decline after dengue infection. The current case series study aims to investigate the baseline frailty status, functional decline, and time to recovery in older adults after dengue infection. Method: We studied seven patients with post-dengue frailty who had been admitted to the geriatric ward in one tertiary medical center in Taiwan during the 2023 dengue fever outbreak. Result: The mean age was 82 years old. The clinical frailty scale worsened from a mean of 4.7 at baseline to 6.3 at dengue diagnosis. The mean Katz Index of independence in activities of daily living decreased from 10.6 at baseline to 4.7 with dengue, and it recovered to 6.7 one month after discharge. Conclusions: Our preliminary data suggest that there is indeed an increase in frailty in older adults due to dengue. Post-dengue frailty and functional decline might be profound and persistent. Acute geriatric care intervention rehabilitation for frailty after dengue may benefit this population.

Community Intervention Team Management of Urology patients in the Community

Introduction: Urinary catheters are a necessary and frequent intervention in the acute clinical setting but can be successfully implemented in a patient’s home with the appropriate protocols. Caredoc Community Intervention Teams (CIT) work closely with local hospitals to establish structured, streamlined referral pathways for patients requiring catheterisation to be managed in the community, thus reducing hospital admissions and visits. Caredoc CIT nurses have been equipped with the requisite skills to successfully manage urology patients, many who are post-operative, outside of the hospital setting, ensuring that this cohort can be managed safely at home with the support of family and/or carers.&#x0D; Aims, Objectives, Theory Or Methods: The purpose of the CIT urology pathway is to provide rapid acute nursing care interventions to patients in their own homes. Patients are identified by urology consultants at local hospitals or by their GPs and referred to CIT for a period of continuous care, with home visits carried out by specialist nurses during a defined timeframe. This facilitates both early hospital discharge and admission avoidance as well as reducing waiting lists for outpatient ambulatory and scheduled care. This shared care initiative aims to transition vital urinary catheter care to the community resulting in a person-centred approach that keeps discharged patients comfortable and well in their own environment.&#x0D; Highlights Or Results Or Key Findings: Patients are managed safely in their own homes by the CIT Team for the duration of their ongoing treatment. By providing a spectrum of catheter care and education, such as teaching patients on the colour of their urinary output, how and when to empty their drainage bag and how to use a fluid balance sheet to record volume emptied, patients are given the knowledge to monitor their urinary output and are enabled to recognise potential red flags for infection and any catheter-related issues that may debilitate or affect their quality of life, with a particular emphasis on the prevention of sepsis in older patients. 24-hour catheter care support is offered by way of a telephone line for patients and their carers should they need advice - prior to the instantiation of the CIT service, patients with subrapubic catheters in residential care or who sought care in the out-of-hours were referred to emergency department via ambulance transfer, as the specialism required for management of these patients was not otherwise available.&#x0D; Conclusions: The CIT Team have successfully demonstrated integrated care pathways for managing patients requiring catheterisation in the community, leading to positive patient outcomes and experiences as well as having a significant impact on urology waiting lists and emergency department attendances. &#x0D; Implications For Applicability/Transferability, Sustainability And Limitations: Sustainability of this process is guided by an integrated, systematic approach to proactive care of people who require catheter care at home, with the aim to improve delivery methods, reduce the burden on acute hospitals and achieve better patient outcomes.

THE QUALITY OF NURSING CARE PROVIDED TO PATIENTS LIVING WITH DEMENTIA: FROM COMMUNICATION- TO FUNCTION-FOCUSED CARE

Abstract Although shortages in nursing abound across all levels of care, it is important that the little time nurses have to engage with patients living with dementia while hospitalized be optimal. The Function Focused Care for Acute Care intervention helps nurses interact with patients living with dementia in a way that engages them in physical activity during all care interactions. This includes such things as walking a patient to the bathroom instead of using a commode chair or bedpan, role modeling for patients and having them wash their face and upper body, walking patients in the hallway when agitated, or doing hand over hand feeding and bathing if the patient is totally dependent. Function focused care provides staff with ways in which to interact with patients living with dementia to be more positive and encouraging with regard to activity and engagement versus neutral or negative. Positive interactions are beneficial in that they encourage participation and engagement in care, neutral interactions are brief and indifferent and provide no encouragement, and negative interactions restrict patients often due to inappropriate safety concerns or for the convenience of the health care team. This symposium will provide an overview of the way in which nurses provide function focused care to patients living with dementia when hospitalized, the quality of care interactions provided and the interventions used in our Function Focused Care work that have helped to improve the percentage of time function focused is provided and the quality of care interactions.

Initiatives to Support the Transition of Patients With Substance Use Disorders From Acute Care to Community-based Services Among a National Sample of Nonprofit Hospitals.

Hospitals are a key touchpoint to reach patients with substance use disorders (SUDs) and link them with ongoing community-based services. Although there are many acute care interventions to initiate SUD treatment in hospital settings, less is known about what services are offered to transition patients to ongoing care after discharge. In this study, we explore what SUD care transition strategies are offered across nonprofit US hospitals. We analyzed administrative documents from a national sample of US hospitals that indicated SUD as a top 5 significant community need in their Community Health Needs Assessment reports (2019-2021). Data were coded and categorized based on the nature of described services. We used data on hospitals and characteristics of surrounding counties to identify factors associated with hospitals' endorsement of transition interventions for SUD. Of 613 included hospitals, 313 prioritized SUD as a significant community need. Fifty-three of these hospitals (17%) offered acute care interventions to support patients' transition to community-based SUD services. Most (68%) of the 53 hospitals described transition strategies without further detail, 23% described scheduling appointments before discharge, and 11% described discussing treatment options before discharge. No hospital characteristics were associated with offering transition interventions, but such hospitals were more likely to be in the Northeast, in counties with higher median income, and states that expanded Medicaid. Despite high need, most US hospitals are not offering interventions to link patients with SUD from acute to community care. Efforts to increase acute care interventions for SUD should identify and implement best practices to support care continuity.

The impact of hospice on end-of-life expenditures and total cost of care in episodic value-based care models at a community oncology network.

228 Background: The Institute of Medicine highlighted that multiple care transitions and fragmented care delivery at the end-of-life (EOL) is a burden to patients and caregivers. Hospice care has been shown to deliver high-quality, coordinated, and comprehensive EOL care while reducing unneeded healthcare interventions and improving EOL patient experience (preference of place of death, type of EOL care). The impact of timely hospice care on Total Cost of Care (TCOC) in episodic value-based care (VBC) models and patient experience at the EOL is largely unknown. The Oncology Care Model (OCM) was a 6-year long Medicare VBC program that encouraged care transformation at Oncology practices to drive better quality of care and patient experience, while decreasing TCOC. We studied the impact of timely hospice enrollment on TCOC, EOL expenditures, and patient experience. Methods: We obtained episode level data for patients who died in an episode (decedents) during the 6-years of the OCM (July 2016 to June 2022), for 15 practices in The US Oncology Network (The Network) participating in the OCM, along with several expenditure, clinical and episodic characteristics. We evaluated utilization and experience outcomes for episodes with and without hospice. Results: Of the 26,074 decedents during the 6-year period of the OCM, 55% were enrolled in hospice for 3 or more days (Hsp), and 45% were not enrolled or enrolled in hospice for less than 3 days (NoHsp). Mean TCOC for Hsp episodes ($41,297, n = 14,240) was significantly lower (Mann Whitney U test, p-value &lt; 0.0001, significance level = 0.01) than NoHsp ($47,601, n = 11,834) episodes. TCOC comparison by expense cohort results are provided in Table 1. Median duration of hospice for Hsp episodes was 9 days. Mean ICU and inpatient spend in last 30 days of life in NoHsp group was more than 2 times the spend in Hsp group. 44% of patients in NoHsp group died in a hospital or an ICU setting, whereas 97% of patients in Hsp group died at home or in a hospice setting. Conclusions: Patients enrolled in hospice for 3 or more days had lower EOL care expenditures, fewer acute care interventions, and died at home or in hospice. Timely and proactive enrollment in hospice and coordinated EOL care can improve patient experience, but also reduce EOL costs for the healthcare system and patients. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.[Table: see text]

Predictors of New Onset Atrial Fibrillation Burden in the Critically Ill

Introduction: Atrial fibrillation (AF) is common in the intensive care unit (ICU) setting and has been associated with adverse outcomes. In this context, there is increasing research interest in AF burden as a predictor of subsequent adverse events. However, the pathophysiology and drivers of AF burden in the ICU are poorly understood. This study sought to evaluate the predictors of AF burden in critical illness-associated new-onset AF (CI-NOAF). Methods: Out of 7,030 admissions in a tertiary general ICU between December 2015 and September 2018, 309 patients developed CI-NOAF. AF burden was defined as the percentage of monitored time in AF, as extracted from hourly interpretations of continuous ECG monitoring. Low and high AF burden groups were defined relative to the median AF burden. Clinical, laboratory, and echocardiographic parameters were extracted, and multivariable modelling with binary logistic regression was performed to evaluate for independent associations with AF burden. Results: The median AF burden was 7.0%. Factors associated with increased AF burden were age, dyslipidaemia, chronic kidney disease, increased creatinine, CHA₂DS₂-VASc score, ICU admission diagnosis category, amiodarone administration, and left atrial area (LAA). Factors associated with lower AF burden were previous alcohol excess, burden of ventilation, the use of inotropes/vasopressors, and beta blockers. On multivariate analysis, increased LAA, chronic kidney disease, and amiodarone use were independently associated with increased AF burden, whereas beta blocker use was associated with lower AF burden. Conclusion: Left atrial size and chronic cardiovascular comorbidities appear to be the primary drivers of CI-NOAF burden, whereas factors related to acute illness and critical care intervention paradoxically did not appear to be a substantial driver of arrhythmia burden. Further research is needed regarding drivers of AF and the efficacy of rhythm control intervention in this unique setting.

Does an Internet-Based Emotion Regulation Intervention Provide Added Value for Acute Psychiatric Inpatient Care? Protocol for a Randomized Controlled Pilot Trial.

There is a lack of studies on internet-based interventions in inpatient settings. This is especially true for studies of internet-based interventions in acute psychiatric inpatient care. Internet-based interventions in this specific setting may provide benefits such as patient empowerment and overall improved treatment outcomes. However, there may also be specific barriers to their implementation that are unique due to the complexity of acute psychiatric inpatient care. The aim of this study is to examine the feasibility and preliminary evidence for effectiveness of a web-based emotion regulation intervention provided as an add-on to acute psychiatric inpatient care. The goal is to randomly allocate 60 patients with a range of different diagnoses in a 1:1 ratio to either treatment as usual (TAU), which consists of acute psychiatric inpatient treatment, or to the intervention group, which will receive TAU plus access to a web-based intervention that focuses on reduction of emotion regulation difficulties and improvement of emotion regulation skills. The primary outcome is symptom severity, assessed with the short form of the Brief Symptom Inventory at baseline, after 4 weeks, after 8 weeks, and at hospital discharge. Secondary outcomes include 2 emotion regulation parameters, intervention use, usability, patient satisfaction, and reasons for patient loss to follow-up. Participant recruitment started in August 2021 and as of March 2023 was ongoing. First publication of study results is expected in 2024. This study protocol describes a study that intends to examine a web-based emotion regulation intervention in acute psychiatric inpatient care. The study will provide information on the feasibility of the intervention and possible effects on symptom severity and emotion regulation. The results will provide new insights on blended treatment, in this case the combination of a web-based intervention and face-to-face psychiatric treatment, in an understudied patient group and setting. ClinicalTrials.gov NCT04990674; https://clinicaltrials.gov/ct2/show/NCT04990674. DERR1-10.2196/47656.

Factors associated with the decision to offer memory making in end-of-life: A survey of healthcare professionals in adult intensive care.

Report experiences and behaviour influences with healthcare professionals' decision to and experiences of offering memory making during end-of-life care in the adult acute population. Little is known about healthcare professionals' experiences offering memory making during adult acute end-of-life care. Survey. Registered nurses, medical practitioners and social workers employed at a single tertiary referral adult intensive care, where memory making had been implemented nearly two years prior were invited to participate between June and August 2017. Reporting adheres to the STROBE checklist. Ninety-six valid surveys (75% response rate: 75 registered nurses, 19medical practitioners, and 2social workers) were analysed with 67 participants reporting experience offering memory making. Highest overall agreement scores included believing families value memory making and the offer of memory making being beneficial. Enablers were described as organisational supports, personal qualities and good interpersonal relationships. Barriers identified included the intensive care environment, workload, inexperience offering/facilitating memory making, being afraid to offer, lack of resources and legality concerns. Compared with non-experienced participants, experienced participants reported higher level of confidence and comfort offering memory making, pride in their ability, ability to spend time supporting families and had observed colleagues offering memory making. Experienced participants were less likely to be afraid to offer, be limited by the family's behaviours, report lack of resources or be time limited to offer memory making. Findings identify elements needed for the development and support for offering memory making to assist bereaved families in adult acute care including role modelling, support to reduce negative emotions, workload assistance and leadership/organisational support. Discoveries have important implications in addressing evidence gaps regarding behaviour influences linked to the decision to offer memory making. Findings inform development and sustainability to integrate memory making as routine end-of-life care intervention in adult acute care.

Adaptive design with bayesian informed interim decisions: application to a randomized trial of mechanical circulatory support

Abstract Background Cardiovascular trials increasingly require large sample sizes and long follow-up periods. Several approaches have been developed to optimize sample size such as adaptive group sequential trials, samples size re-estimation based on the promising zone, and the win ratio. Traditionally, the log-rank or the Cox proportional hazards model is used to test for treatment effects, based on a constant hazard rate and proportional hazards alternatives, which however, may not always hold. Large sample sizes and/or long follow up periods are especially challenging for trials evaluating the efficacy of acute care interventions. Purpose We propose an adaptive design wherein using interim data, Bayesian computation of predictive power guides the increase in sample size and/or the minimum follow-up duration. These computations do not depend on the constant hazard rate and proportional hazards assumptions, thus yielding more robust interim decision making for the future course of the trial. Methods PROTECT IV is designed to evaluate mechanical circulatory support with the Impella CP device vs. standard of care during high-risk PCI. The primary endpoint is a composite of all-cause death, stroke, MI or hospitalization for cardiovascular causes with initial minimum follow-up of 12 months and initial enrolment of 1252 patients with expected recruitment in 24 months. The study will employ an adaptive increase in sample size and/or minimum follow-up at the Interim analysis when ∼80% of patients have been enrolled. The adaptations utilize extensive simulations to choose a new sample size up to 2500 and new minimal follow-up time up to 36 months that provides a Bayesian predictive power of 85%. Bayesian calculations are based on patient-level information rather than summary statistics therefore enabling more reliable interim decisions. Constant or proportional hazard assumptions are not required for this approach because two separate Piece-wise Constant Hazard Models with Gamma-priors are fitted to the interim data. Bayesian predictive power is then calculated using Monte-Carlo methodology. Via extensive simulations, we have examined the utility of the proposed design for situations with time varying hazards and non-proportional hazards ratio such as situations of delayed treatment effect (Figure) and crossing of survival curves. The heat map of Bayesian predictive power obtained when the interim Kaplan-Meier curves reflected delayed response shows that for this scenario an optimal combination of increased sample size and increased follow-up time would be needed to attain 85% predictive power. Conclusion A proposed adaptive design with sample size and minimum follow-up period adaptation based on Bayesian predictive power at interim looks allows for de-risking the trial of uncertainties regarding effect size in terms of control arm outcome rate, hazard ratio, and recruitment rate. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abiomed, Inc Figure 1

Hospital at home for acute medical illness: The 21st century acute medical unit for a changing population.

Recent trends across Europe show a year-on-year increase in the number of patients with acute medical illnesses presenting to hospitals, yet there are no plans for a substantial expansion in acute hospital infrastructure or staffing to address demand. Strategies to meet increasing demand need to consider the fact that there is limited capacity in acute hospitals and focus on new care models in both hospital and community settings. Increasing the efficiency of acute hospital provision by reducing the length of stay entails supporting acute ambulatory care, where patients receive daily acute care interventions but do not stay overnight in the hospitals. This approach may entail daily transfer between home and an acute setting for ongoing treatment, which is unsuitable for some patients living with frailty. Acute hospital at home (HaH) is a care model which, thanks to advances in point of care diagnostic capability, can provide a credible model of acute medical assessment and treatment without the need for hospital transfer. Investment and training to support scaling up of HaH are key strategic aims for integrated healthcare systems.

Role of the pharmacist in acute care interventions for opioid use disorder: A scoping review

AbstractOpioid use disorder (OUD) is associated with significant morbidity and mortality in the United States. In recent years, interest in initiatives to increase access to medication for OUD (MOUD) and overdose‐reversing medications (naloxone) in acute care has grown. While well positioned to intervene, the role of acute care pharmacists in these interventions is not known. The objective for this scoping review was to better understand what is presently known about the role of pharmacists in acute care OUD interventions. These were defined as initiatives implemented in either inpatient or emergency department (ED) settings aimed at treatment of OUD (eg, initiation or management of MOUD) or harm reduction in individuals with OUD (eg, education or targeted naloxone dispensing). PubMed/MEDLINE and Embase databases were searched for articles pertaining to the research question from inception to 19 May 2021. Pearling was performed after the identification of eligible articles. Articles had to explicitly describe the pharmacist's role in planning, implementing, or evaluating an OUD intervention in the inpatient or ED setting. Data charting was performed by both authors using a predefined template, and data synthesis was performed via discussion between authors. The initial title search yielded 101 references which were screened and resulted in four articles that met inclusion criteria. Three additional articles were identified in the pearling process, yielding a total of seven articles. Four described initiatives aimed at point‐of‐care dispensing of naloxone, and three described initiatives for provision or management of MOUD. Pharmacist roles primarily consisted of medication use process management, hospital staff and patient education, and dispensing activities. Literature describing the role of pharmacists in acute care OUD interventions is limited. Given the burden of OUD, there are many opportunities for further exploration of the roles acute care pharmacists can play in OUD harm reduction and treatment.

Pharmacologic Recruitment of Endogenous Neural Stem/Progenitor Cells for the Treatment of Spinal Cord Injury.

Laboratory study using a rat T9 contusion model of spinal cord injury. This study aims to examine whether a combinatory treatment of Pioglitazone (PGZ) and granulocyte colony-stimulating factor (GCSF) can support neural stem/progenitor cells (NSPCs) directly and provide a sustainable microenvironment through immunomodulatory mechanisms. Neuroinflammation plays a crucial role in the progression of spinal cord injury (SCI) and hinders NSPC-mediated repair and regeneration. Broad acting drugs that mitigate inflammation and support NSPC proliferation have not been tested together in SCI research models. Isolated NSPCs were treated with vehicle control, PGZ, GCSF, or both PGZ and GSCF for 24 hours and stained with proliferation marker Ki67. Adult female Sprague-Dawley rats sustained moderate-to-severe contusion-based SCI at T9 and were administered either vehicle control, PGZ, GCSF, or both PGZ and GCSF treatments. Immunocytochemistry revealed that cultured NSPCs treated with both drugs produced higher numbers of actively proliferating cells and total cell numbers. ELISA on spinal cord tissue lysates at 1, 3, and 7 days post-injury (DPI) demonstrated that animals treated with PGZ, GCSF, or combination therapy showed significantly higher doublecortin levels at 7 DPI compared to control animals (P < 0.05). Immunohistochemistry of injured tissue at 3, 7, and 14 DPI revealed no difference of ependymal NSPC proliferation between groups, but showed a significant decrease in lesion size with combination therapy compared to controls. Functional recovery was assessed by the Basso, Beattie, Bresnahan locomotor rating scale. Animals treated with both drugs had significantly higher levels of function at 1 (P < 0.001), 3 (P < 0.001), 7 (P < 0.05), and 14 (P < 0.05) DPI compared to controls. These results indicate that PGZ and GCSF treatment synergistically enhance NSPCs numbers and improve functional recovery after SCI. Our findings support an immunomodulatory strategy to recruit native NSPCs as a potential acute care intervention for SCI.Level of Evidence: N/A.

Adaptive design with bayesian informed interim decisions: application to a randomized trial of mechanical circulatory support

Abstract Background Cardiovascular trials increasingly require large sample sizes and long follow-up periods. Several approaches have been developed to optimize sample size such as adaptive group sequential trials, samples size re-estimation based on the promising zone, and the win ratio. Traditionally, the log-rank or the Cox proportional hazards model is used to test for treatment effects, based on a constant hazard rate and proportional hazards alternatives, which however, may not always hold. Large sample sizes and/or long follow up periods are especially challenging for trials evaluating the efficacy of acute care interventions. Purpose We propose an adaptive design wherein using interim data, Bayesian computation of predictive power guides the increase in sample size and/or the minimum follow-up duration. These computations do not depend on the constant hazard rate and proportional hazards assumptions, thus yielding more robust interim decision making for the future course of the trial. Methods PROTECT IV is designed to evaluate mechanical circulatory support with the Impella CP device vs. standard of care during high-risk PCI. The primary endpoint is a composite of all-cause death, stroke, MI or hospitalization for cardiovascular causes with initial minimum follow-up of 12 months and initial enrolment of 1252 patients with expected recruitment in 24 months. The study will employ an adaptive increase in sample size and/or minimum follow-up at the Interim analysis when ∼80% of patients have been enrolled. The adaptations utilize extensive simulations to choose a new sample size up to 2500 and new minimal follow-up time up to 36 months that provides a Bayesian predictive power of 85%. Bayesian calculations are based on patient-level information rather than summary statistics therefore enabling more reliable interim decisions. Constant or proportional hazard assumptions are not required for this approach because two separate Piece-wise Constant Hazard Models with Gamma-priors are fitted to the interim data. Bayesian predictive power is then calculated using Monte-Carlo methodology. Via extensive simulations, we have examined the utility of the proposed design for situations with time varying hazards and non-proportional hazards ratio such as situations of delayed treatment effect (Figure) and crossing of survival curves. The heat map of Bayesian predictive power obtained when the interim Kaplan-Meier curves reflected delayed response shows that for this scenario an optimal combination of increased sample size and increased follow-up time would be needed to attain 85% predictive power. Conclusion A proposed adaptive design with sample size and minimum follow-up period adaptation based on Bayesian predictive power at interim looks allows for de-risking the trial of uncertainties regarding effect size in terms of control arm outcome rate, hazard ratio, and recruitment rate. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abiomed, Inc Figure 1

Ethical Issues in the Care of Emerging Adults in Pediatric Intensive Care Units.

Ethical Issues in the Care of Emerging Adults in Pediatric Intensive Care Units.

Patient experiences of integrated care within the United Kingdom: A systematic review

Introduction Integrated care and patient experience are central to the coordination and delivery of high quality health and social care in the UK, but their joint application is poorly understood. This systematic review aimed to gain an understanding of patient experience within current integrated care services in the UK, and specifically, whether they reflect person-centred coordinated care (PCCC). Methods Following PRISMA, electronic databases (ProQuest, EBSCO and Cochrane Library) were searched from 2012 to 2019 for primary, peer-reviewed literature. Papers were included where patients’ or carers’ experiences of integrated care were reported. Papers were excluded where they focused on acute integrated care interventions, measured experience via satisfaction scores only, or findings lacked sufficient depth to answer the research question. Quality was assessed using Mixed Methods Appraisal Tool, and findings synthesised using a framework approach, incorporating the Rainbow Model of Integrated Care and Measuring Integrated Care Patient Framework. Results Sixteen studies were included. Person-centred and shared responsibility experiences were most often discussed. Experiences were not always described as positive and some patients experienced a lack of PCCC. Clinical, professional/organisational and functional integration processes were associated with experiencing domains of PCCC. Discussion People with complex needs experience a lack of coordination across teams and wider community resources, and limited associations were made between integration processes and patient experience. Further research which gives context to individual experience, provides greater detail of integration processes and utilises validated patient experience measures of PCCC is required to understand the association between integration processes and domains of PCCC.

REVIEW OF PHYSIOLOGICAL RATIONALE OF PHYSIOTHERAPY IN COVID-19 PATIENTS: A CASE SERIES

Physiotherapy interventions have been evidenced to assist early liberation from ICU in COVID-19 patients. This case series of three COVID patients admitted to the COVID ICU, explains the physiologic rationale of physiotherapy intervention in acute care of COVID patients. Early mobilization is seen to help early recovery. KEY WORDS: Physiologic rationale, COVID, physiotherapy, crocodile breathing.